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Based on document review and staff interviews, the CAH's administrative staff failed to ensure the CAH's emergency department staff followed the CAH's policies when the ED staff failed to ensure they provided an appropriate medical screening examination for 1 of 20 medical records reviewed (Patient #1). Failure to follow the CAH's policies resulted in the ED staff discharging a patient to jail while the ED staff actively attempted to complete an involuntary mental health committal on Patient #1, which delayed Patient #1 from receiving appropriate inpatient psychiatric care. The CAH's administrative staff identified an average of 450 patients per month who presented to the CAH's dedicated emergency department and requested emergency care.


Findings include:

1. Review of the policy "Transfer and Emergency Examination", effective 3/2001, revealed in part, "Emergency Medical Condition (EMC), a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention... a. Place the health of the individual in serious jeopardy; or b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organs or part..."

"A Medical Screening Examination (MSE)... an examination within the capability of the Hospital's Emergency Department... to determine with reasonable clinical confidences whether an EMC exists." "Stabilize ... To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result ..." "Stabilization or admission if emergency medical condition is found ... If the individual has an EMC, further examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the EMC ..."



2. Review of Patient #1's medical record revealed the following:

a. Patient #1 arrived at Myrtue Medical Center (MMC) ED on 2/12/22 at 4:41 PM, seeking pain relief for a hand burn Patient #1 sustained during a recent house fire. Physician A documented that during the ED visit, Patient #1 was aggressive, scared other individuals in the waiting room, was insulting to the nursing staff and Physician A, and Patient #1 was seeking pain medication.

b. At 4:50 PM, RN E documented that Patient #1 presented to the hospital's ED. Patient #1 was yelling at RN E and Physician A. Patient #1 requested pain medication. Patient #1 threatened the ED staff and then left the ED.

c. At 5:17 PM, Physician A documented they had assessed Patient #1's hand (which Patient #1 claimed was burned in a recent house fire). Physician A documented that Patient #1 did not have any wounds or blisters on the hand Patient #1 claimed was burned.

d. At 5:31 PM, Physician A documented, "Had [police officers] come [to the Emergency Department]. Told [Patient #1 they] would not get pain medication and [Patient #1] stormed out. I have filled out committal paperwork as I do believe inpatient psychiatric care is needed but as [Patient #1] has not threatened self-harm but [Patient #1] is a complete disrupter of the ER department, I'm hoping [Patient #1] can be kept in jail pending placement as [Patient #1] can not be kept in our facility for the 2 to 3 days it would be normally take to find [inpatient psychiatric care] placement". Physician A further documented that Physician A had completed paperwork to request the court involuntarily commit Patient #1 to an inpatient mental health unit.

e. At 7:22 PM, (approximately 3 hours after Patient #1 first presented to the ED), the local police officers brought Patient #1 back to the ED. The local police officers responded to a report of an individual behaving inappropriately and disruptively at a local grocery store. While the police officers arrested Patient #1, Patient #1 began hyperventilating. The police officers took Patient #1 to the ED evaluation of Patient #1's medical condition.

f. At 7:26 PM, RN F documented that Patient #1 exhibited very manic behaviors. Patient #1 spoke very quickly, frequently changed the topic of conversation (even during the same sentence), and RN F could not keep Patient #1 on topic long enough to have a conversation with Patient #1.

g. At 7:42 PM, Physician A documented Patient #1 was exhibiting manic behaviors, Patient #1 spoke very rapidly and frenzied in a very urgent manner, and Patient #1 would change conversation topics so frequently that Physician A could not follow Patient #1's conversation. Physician A documented that Patient #1 was brought to the ED by the local police officers for evaluation prior to the police officers taking Patient #1 to jail. During Physician A's examination of Patient #1, Patient #1 was less angry than during Patient #1's ED visit a few hours prior. Patient #1 was tearful and informed Physician A that Patient #1 needed assistance sleeping. Physician A prescribed medication to help Patient #1 sleep.

Physician A indicated that Physician A was still working on the paperwork to involuntarily commit Patient #1 to an inpatient mental health unit. Physician A diagnosed Patient #1 with bipolar disorder and severe mania (a psychiatric emergency medical condition).

h. At 7:45 PM, Physician A documented on the jail inmate medical clearance report that Patient #1 was seen for "agitation" and Patient #1 was stable for discharge to the jail in police custody.

i. At 8:26 PM, the ED staff discharged Patient #1 to jail, with Patient #1 in police custody.

k. On 2/12/22, Physician A completed the legal paperwork to request Patient #1 be involuntarily committed for inpatient mental health care. Physician A documented that Patient #1 had presented to the ED 3 times. Each time Patient #1 presented to the ED, Patient #1 was in a manic state (potentially a psychiatric emergency medical condition) and demanded that the ED staff provide Patient #1 with pain medication. Patient #1 was very aggressive and threatened the ED staff. Patient #1 was not compliance with the recommended outpatient treatment of Patient #1's bipolar disorder and mania, which necessitated Patient #1 receiving involuntary inpatient mental health treatment. Due to Patient #1's behaviors, Physician A felt Patient #1 was not safe to wait in the hospital's ED for the hospital staff to identify and transfer Patient #1 to an inpatient mental health bed (despite Physician A documenting Patient #1 was experiencing a psychiatric emergency medical condition).

l. On 2/16/22 (4 days after Patient #1's arrest), the ED Manager completed the legal paperwork to request Patient #1 be involuntarily committed for inpatient mental health care. The ED Manager documented that Patient #1 had presented 3 times to the ED. Each time Patient #1 presented to the ED, Patient #1 was in a manic state. Patient #1 would call the ED staff names and threatened the ED staff. The ED staff could not reason with Patient #1, due to Patient #1's mental health issues. Physician A had provided the police officers with a copy of Physician A's involuntary mental health committal application when the officers took Patient #1 to jail. The police released Patient #1 from jail on 2/13/22 (the day after Patient #1's ED visit). Further review of the paperwork revealed that the County Magistrate approved the involuntary committal for Patient #1 to receive inpatient mental health care on 2/16/22 (4 days after Patient #1 presented to the ED).



3. During an interview on 4/4/22 at 12:20 PM, Physician A revealed that Patient #1 presented to the ED in a very manic state. Despite Patient #1's manic behaviors, Physician A was not concerned about Patient #1's safety. Instead, Physician A felt Patient #1 needed to be kept away from the ED staff and other ED patients, due to Patient #1's behaviors. Physician A felt that Patient #1 required involuntary mental health treatment, but due to Patient #1's behaviors, the ED staff could not provide adequate care for Patient #1 while the ED staff attempted to find an available inpatient mental health bed for Patient #1. Physician A felt that Patient #1 would be safer in jail, instead of the ED, while staff attempted to identify an inpatient mental health bed available for Patient #1.

Physician A then identified that a patient would need involuntary court committal for inpatient mental health if the patient threatened to harm themselves, threatened others (which Patient #1 did), was known to not regularly take their medication (which Physician A documented Patient #1 did), and if the individual had known complaints to the police department (which Patient #1 had).


4. During an interview on 4/4/22 at 2:20 PM, the County Magistrate indicated the ED staff brought Patient #1's involuntary inpatient mental health committal paperwork to the county courthouse on 2/16/22 (4 days after Patient #1 was in the ED). Physician A felt Patient #1 was drug seeking. The ED staff had not provided any treatment to Patient #1 to address Patient #1's psychiatric emergency medical condition, but the ED staff felt Patient #1 should be involuntarily committed for inpatient mental health treatment. The ED staff never keep psychiatric patients in the CAH's ED, as the CAH's ED lacked sufficient staff to adequately provide care to psychiatric patients.


Please see C-2406 for additional information.

Based on document review and staff interviews, the CAH's administrative staff failed to ensure the CAH's emergency department staff provided an adequate medical screening examination to 1 of 14 reviewed emergency department patients (Patient #1). Failure to provide an adequate medical screening examination resulted in the CAH staff potentially failing to identify the underlying cause of Patient #1's behavior and then failing to ensure Patient #1 received inpatient mental health treatment after identifying Patient #1 was experiencing a psychiatric emergency medical condition. The CAH's administrative staff identified an average of 450 patients per month who presented to the CAH's dedicated emergency department and requested emergency care.


Findings include:

1. Record review of Patient #1 revealed the following:

a. Patient #1 arrived at Myrtue Medical Center (MMC) ED on 2/12/22 at 4:41 PM, seeking pain relief for a hand burn Patient #1 sustained during a recent house fire. Physician A documented that during the ED visit, Patient #1 was aggressive, scared other individuals in the waiting room, was insulting to the nursing staff and Physician A, and Patient #1 was seeking pain medication.

b. At 4:50 PM, RN E documented that Patient #1 presented to the hospital's ED. Patient #1 was yelling at RN E and Physician A. Patient #1 requested pain medication. Patient #1 threatened the ED staff and then left the ED.

c. At 5:17 PM, Physician A documented they had assessed Patient #1's hand (which Patient #1 claimed was burned in a recent house fire). Physician A documented that Patient #1 did not have any wounds or blisters on the hand Patient #1 claimed was burned.

d. At 5:31 PM, Physician A documented, "Had [police officers] come [to the Emergency Department]. Told [Patient #1 they] would not get pain medication and [Patient #1] stormed out. I have filled out committal paperwork as I do believe inpatient psychiatric care is needed but as [Patient #1] has not threatened self-harm but [Patient #1] is a complete disruptor of the ER department, I'm hoping [Patient #1] can be kept in jail pending placement as [Patient #1] can not be kept in our facility for the 2 to 3 days it would be normally take to find [inpatient psychiatric care] placement". Physician A further documented that Physician A had completed paperwork to request the court involuntarily commit Patient #1 to an inpatient mental health unit.

e. At 7:22 PM, (approximately 3 hours after Patient #1 first presented to the ED), the local police officers brought Patient #1 back to the ED. The local police officers responded to a report of an individual behaving inappropriately and disruptively at a local grocery store. While the police officers arrested Patient #1, Patient #1 began hyperventilating. The police officers took Patient #1 to the ED evaluation of Patient #1's medical condition.

f. At 7:26 PM, RN F documented that Patient #1 exhibited very manic behaviors. Patient #1 spoke very quickly, frequently changed the topic of conversation (even during the same sentence), and RN F could not keep Patient #1 on topic long enough to have a conversation with Patient #1.

g. At 7:42 PM, Physician A documented Patient #1 was exhibiting manic behaviors, Patient #1 spoke very rapidly and frenzied in a very urgent manner, and Patient #1 would change conversation topics so frequently that Physician A could not follow Patient #1's conversation. Physician A documented that Patient #1 was brought to the ED by the local police officers for evaluation prior to the police officers taking Patient #1 to jail. During Physician A's examination of Patient #1, Patient #1 was less angry than during Patient #1's ED visit a few hours prior. Patient #1 was tearful and informed Physician A that Patient #1 needed assistance sleeping. Physician A prescribed medication to help Patient #1 sleep.

Physician A indicated that Physician A was still working on the paperwork to involuntarily commit Patient #1 to an inpatient mental health unit. Physician A diagnosed Patient #1 with bipolar disorder and severe mania (a psychiatric emergency medical condition).

h. At 7:45 PM, Physician A documented on the jail inmate medical clearance report that Patient #1 was seen for "agitation" and Patient #1 was stable for discharge to the jail in police custody.

i. At 8:26 PM, the ED staff discharged Patient #1 to jail, with Patient #1 in police custody.

k. On 2/12/22, Physician A completed the legal paperwork to request Patient #1 be involuntarily committed for inpatient mental health care. Physician A documented that Patient #1 had presented to the ED 3 times. Each time Patient #1 presented to the ED, Patient #1 was in a manic state (potentially a psychiatric emergency medical condition) and demanded that the ED staff provide Patient #1 with pain medication. Patient #1 was very aggressive and threatened the ED staff. Patient #1 was not compliance with the recommended outpatient treatment of Patient #1's bipolar disorder and mania, which necessitated Patient #1 receiving involuntary inpatient mental health treatment. Due to Patient #1's behaviors, Physician A felt Patient #1 was not safe to wait in the hospital's ED for the hospital staff to identify and transfer Patient #1 to an inpatient mental health bed (despite Physician A documenting Patient #1 was experiencing a psychiatric emergency medical condition).

l. On 2/16/22 (4 days after Patient #1's arrest), the ED Manager completed the legal paperwork to request Patient #1 be involuntarily committed for inpatient mental health care. The ED Manager documented that Patient #1 had presented 3 times to the ED. Each time Patient #1 presented to the ED, Patient #1 was in a manic state. Patient #1 would call the ED staff names and threatened the ED staff. The ED staff could not reason with Patient #1, due to Patient #1's mental health issues. Physician A had provided the police officers with a copy of Physician A's involuntary mental health committal application when the officers took Patient #1 to jail. The police released Patient #1 from jail on 2/13/22 (the day after Patient #1's ED visit). Further review of the paperwork revealed that the County Magistrate approved the involuntary committal for Patient #1 to receive inpatient mental health care on 2/16/22 (4 days after Patient #1 presented to the ED).



2. During an interview on 4/4/22 at 12:20 PM, Physician A revealed that Patient #1 presented to the ED in a very manic state. Despite Patient #1's manic behaviors, Physician A was not concerned about Patient #1's safety. Instead, Physician A felt Patient #1 needed to be kept away from the ED staff and other ED patients, due to Patient #1's behaviors. Physician A felt that Patient #1 required involuntary mental health treatment, but due to Patient #1's behaviors, the ED staff could not provide adequate care for Patient #1 while the ED staff attempted to find an available inpatient mental health bed for Patient #1. Physician A felt that Patient #1 would be safer in jail, instead of the ED, while staff attempted to identify an inpatient mental health bed available for Patient #1.

Physician A then identified that a patient would need involuntary court committal for inpatient mental health if the patient threatened to harm themselves, threatened others (which Patient #1 did), was known to not regularly take their medication (which Physician A documented Patient #1 did), and if the individual had known complaints to the police department (which Patient #1 had).


3. During an interview on 4/4/22 at 12:50 PM, the ED Manager revealed that the ED staff tries to keep patients in the ED who require inpatient psychiatric care, while looking to identify an appropriate inpatient mental health bed for the patient. However, the ED staff can not keep a patient who required inpatient psychiatric care if that patient would place the other ED patients in danger. The ED staff would rely on administering dangerous patients medications to help calm them down (which Patient #1 did not receive) and utilizing the local police officers to help keep patients safe. Additionally, the CAH staff rely on a tele-psychiatry service to provide mental health practitioners, who determine if a patient required inpatient or outpatient mental health treatment (Patient #1 did not receive this service).


4. During an interview on 4/4/22 at 3:00 PM, RN E revealed they provided care to Patient #1 during Patient #1's first ED visit, but RN E left work prior to Physician A discharging Patient #1 the first time. RN E indicated that normally, once the ED staff complete the involuntary inpatient mental health committal paperwork, the ED staff contact the county magistrate (a lawyer with limited judicial authority) and the magistrate will issue a court order for the involuntary mental health commitment.


5. During an interview on 4/4/22 at 2:20 PM, the County Magistrate indicated the ED staff brought Patient #1's involuntary inpatient mental health committal paperwork to the county courthouse on 2/16/22 (4 days after Patient #1 was in the ED). Physician A felt Patient #1 was drug seeking. The ED staff had not provided any treatment to Patient #1 to address Patient #1's psychiatric emergency medical condition, but the ED staff felt Patient #1 should be involuntarily committed for inpatient mental health treatment. The ED staff never keep psychiatric patients in the CAH's ED, as the CAH's ED lacked sufficient staff to adequately provide care to psychiatric patients.